Mari Wargo-Dorsey Lapidus Bunionectomy: First Metatarsal– Cuneiform Arthrodesis · 2013-04-04 ·...

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C H A P T E R

31Lapidus Bunionectomy: First Metatarsal–Cuneiform Arthrodesis

Lawrence A. DiDomenicoMari Wargo-Dorsey

Metatarsus primus varus and hallux abducto valgus (HAV) have been used to correct HAV since originally described by Albrecht (1) in 1911. Truslow (2) followed with a version of the procedure in 1925 that involved a wedged resection of bone from the fi rst metatarsocuneiform joint. The procedure was later popularized by and named after Paul Lapidus. In 1930, he proposed a fi rst metatarsal–cuneiform arthrodesis paired with arthrodesis of the second metatarsal as well as resection of the dorsomedial eminence of the fi rst metatarsal head and distal soft tissue repositioning for metatarsus primus varus. He believed that metatarsus primus varus was the result of an underdeveloped atavistic foot type. He hypothesized that hypermobility of the fi rst metatarsal– cuneiform joint combined with an increased fi rst to second intermetatarsal (IM) angle caused by an oblique joint axis predisposes the foot to HAV and metatarsus primus varus. Lapidus concluded that the apex of the deformity, the fi rst metatarsal–cuneiform joint, needed to be addressed or a “bayonet-shaped” deformity would result (3).

While many techniques have been described modifying the original Lapidus procedure, all use arthrodesis of the metatar-sal–cuneiform joint (4–11). The procedure allows for triplanar correction of fi rst metatarsal pathology, increases the biome-chanical advantage of the peroneus longus, and has the ability to stabilize the medial column. The fi rst metatarsal–cuneiform arthrodesis, while controversial, is a versatile procedure that can correct numerous pathologies.

EVALUATION/DIAGNOSIS/FUNCTIONAL ANATOMY

Traditionally, the fi rst metatarsal–cuneiform arthrodesis has been used to correct for a hypermobile fi rst ray. When the fi rst metatarsal possesses increased motion of the fi rst metatarsal–cuneiform joint, the metatarsal elevates during gait, mak-ing the fi rst ray unstable and unable to maintain its position against ground reaction forces throughout the gait cycle (12). Numerous attempts have been made to defi ne hypermobility in both the sagittal and transverse planes although no stand-ardized values exist. Clinical assessment of the fi rst ray range of motion is still currently the most accepted method to diag-nose hypermobility of the fi rst ray. Root described normal fi rst ray motion as equal dorsal and plantar range of motion and hypermobility as anything beyond equal motion in the sagittal plane. He placed the ankle joint and subtalar joints in neutral position and then stabilized metatarsal heads 2 to 5 with one hand and the fi rst metatarsal head with the other hand, while taking the fi rst metatarsal through its range of motion (13,14). Later, one thumb’s breadth of dorsal motion was described as

hypermobile when using Root’s technique (15). Roukis et al have promoted the “dynamic Hicks test,” in which the foot is tested with the hands positioned in the same manner as Root described. The hallux is then fully dorsifl exed at the fi rst meta-tarsophalangeal joint, and dorsal and plantar pressures are then applied to the metatarsal head. The results of the “dynamic Hicks test” are then compared with those of Root’s; they believe that true hypermobility of the fi rst ray exists when both tests show a positive result of hypermobility (16). Radiographically, hypermobility is frequently distinguished on anteroposterior radiograph as an increased fi rst to second IM angle with medial cortical thickening of the second metatarsal, which is believed to be due to second metatarsal overload (17). Clinically, this can be accompanied with a hyperkeratotic lesion plantar to the second metatarsal head (18). Some advocate the test for evalu-ation of transverse plane hypermobility, which entails wrap-ping an ACE wrap across the forefoot while applying moderate tightness (19,20). Radiographs with the ACE wrap applied are compared with normal weight-bearing radiographs to assess if hypermobility of the joint occurs in the transverse plane, which can be seen with a decreased IM angle with the apex of deform-ity at the fi rst metatarsal–cuneiform joint. Hypermobility is frequently concomitant with a large HAV deformity, although mild to moderate cases of HAV have been treated successfully when fi rst ray hypermobility is present (5,12,21–23). The pro-cedure is also indicated when generalized ligamentous laxity is seen with HAV.

Juvenile HAV frequently is accompanied by hypermobility at the fi rst metatarsal–cuneiform joint. Adolescent HAV dif-fers from adult HAV in that a smaller dorsomedial eminence is present and less valgus rotation of the hallux occurs (24,25). If hypermobility is present and not addressed, recurrence of the deformity may result, as juvenile HAV frequently is a structural problem that can persist throughout adulthood and progress (12,22). It has been demonstrated that the angle created by the axis of the fi rst metatarsal and the distal surface of the medial cuneiform is increased with statistical signifi cance in Juvenile HAV, supporting that varus angulation occurs proximal to the metatarsal at the level of the fi rst metatarsal–cuneiform joint. A positive correlation also exists between the angle created by the distal surface of the medial cuneiform and the axis of the second metatarsal and an increased IM angle (26). Lower recurrence rates have been achieved with this procedure as it addresses the deformity at its apex and eliminates fi rst ray hypermobility (17,22,27). Juvenile HAV corrected with other procedures has been noted to have recurrence rates as high as 35% (27,28). The procedure is an excellent option for cor-rection of Juvenile HAV as it can be performed successfully without resection of the medial eminence and distal soft tissue release (17).

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Chapter 31 • Lapidus Bunionectomy: First Metatarsal–Cuneiform Arthrodesis 323

Moderate to severe HAV can be treated effectively with this procedure without the presence of hypermobility. IM angles rang-ing from 14 to 30 degrees on anteroposterior radiograph have been used as a baseline for the procedure (24,29). Etiology of an increased IM angle may be due to the shape of the fi rst MC joint itself, as a positive correlation exists between the obliqueness of the joint and increased fi rst to second IM angle (30). Surgical cor-rection of large IM angles needs to be addressed with proximal procedures, as the long lever arm allows for a higher level degree of correction as opposed to distal procedures. The procedure has the ability to restore fi rst metatarsophalangeal joint congru-ency and realign the sesamoid apparatus in addition to correc-tion of the IM angle. The closing base wedge osteotomy (CBWO) and the modifi ed Lapidus were compared and both procedures demonstrated signifi cant fi rst to second IM correction, with the Lapidus maintaining a greater degree of correction postopera-tively, the CBWO losing an average of 2.55 degrees of correction and the Lapidus losing only an average of 1.08 degrees (31).

More recently, the procedure has been used in conjunction with other procedures as a practical option for treatment of medial column insuffi ciency and fl atfoot deformity. Addressing the medial column for these pathologies is vital as the fi rst meta-tarsal can accommodate up to 50% of the stress experienced through gait and provides a paramount role in stabilizing the medial longitudinal arch (32). It is important to note that the procedure is not advocated for primary correction of these pathologies. Morton described what has become known as a “Morton’s foot” in which the fi rst metatarsal is anatomically or functionally short, leading to rotation about the axis of the fore-foot causing pronation (33–37). The goal of surgical correction of a “Morton’s foot” is to stabilize the medial column and realign the parabola of the metatarsal heads to distribute weight-bearing evenly. The peroneus longus muscle gains mechanical advan-tage following a Lapidus procedure contributing to functional stability of the medial column, which is lost with pronation of the foot (38,39). In 2008, Avino et al performed radiographic analysis on 39 feet in which an isolated Lapidus was performed to review the effects of the arthrodesis to the medial column in the sagittal plane. Postoperatively, the mean cuneiform increase in height was 3.44 mm and Meary’s angle decreased by a mean of 2.97 degrees (40). Logel et al examined the effects of calcane-ocuboid arthrodesis and fi rst metatarsal–cuneiform arthrodesis on lateral column pressure as well as radiographic correction of fl atfoot deformity on 10 fresh frozen cadaver limbs. They found that with the lateral column lengthening procedure alone there was improved radiographic measurements when evaluating lat-eral talus–fi rst metatarsocuneiform angle, talonavicular cover-age angle, medial column height, lateral talus–calcaneal angle, and calcaneal pitch; however, increased lateral column pressures were noted. They subsequently performed a fi rst metatarsal–cuneiform arthrodesis on the same limbs, which decreased pressure of the lateral column and the radiographic values dem-onstrated additional increased correction (41). This procedure has been successfully used when medial column insuffi ciency is present in conditions such as Charcot-Marie-Tooth and postpo-lio when restoration and stability of the medial column is essen-tial to restore function of the foot (4,42).

Degenerative joint disease (DJD) of the fi rst metatarsal– cuneiform joint can be successfully treated with arthrodesis of the joint. DJD can be the result of arthritides, trauma, and long- standing biomechanical abnormalities (11,17,43). The pain expe-rienced with the DJD is corrected with arthrodesis of the joint.

Failed HAV procedures may also elicit the need of arthrode-sis of the Lapidus procedure as it can maintain good functional results (44). If the deformity returns following initial surgical correction, hypermobility of the fi rst metatarsal–cuneiform joint needs to be assessed as well as generalized ligamentous laxity to determine if excessive movement of the joint was etiol-ogy of recurrence. A bone graft may need to be incorporated into the joint to maintain length and restore function as the prior procedure may have shortened the fi rst metatarsal.

Hallux limitus and metatarsal primus elevatus may also be corrected with this procedure (21,45). With intraoperative plantarfl exion of the fi rst metatarsal, decompression of the fi rst metatarsophalangeal joint occurs, allowing for increased motion of the joint.

CRITERIA/SELECTION OF PROCEDURE/CONTRAINDICATIONS

Inclusion criteria for the Lapidus procedure for HAV and meta-tarsus primus varus include a pathologic hypermobile fi rst ray, moderate to severe HAV with or without the presence of hyper-mobility with a fi rst to second IM angle greater than 15 degrees, HAV with concurrent generalized ligamentous laxity, adoles-cent HAV (Fig. 31.1), or instability at the tarsal–metatarsal joint in the sagittal, transverse, and/or frontal plane. The procedure can be used as an adjunctive procedure for correction of pes planovalgus deformity and hallux rigidus deformity, in patients who present with a sub–second metatarsal callous/lesion, or in conditions where tarsal–metatarsal instability exists (Fig. 31.2). Arthrodesis of the fi rst metatarsal–cuneiform joint can be per-formed in the presence of painful degenerative joint and for decompression of the fi rst metatarsophalangeal joint seen with hallux limitus and metatarsus primus elevatus.

Figure 31.1 Preoperative HAV deformity. Note the valgus rotation of the great toe


324 Part III • First Ray, Hallux Abducto Valgus, and Related Deformities

The main contraindication of the Lapidus procedure is an exceedingly short fi rst ray due to the shortening that is inevita-ble with resection of the joint. When this does occur, techniques have been described that use grafts in order to facilitate and lengthen the metatarsal–tarsal complex. A relative contrain-dication is juveniles with HAV when the epiphyses are open; however, the procedure can be performed with open epiphyses if fi xation is performed with smooth Kirschner wires (K-wires) (46). Another relative contraindication is a young, athletic per-son where postoperative stiffness could follow and add morbid-ity to their active lifestyle (47). A foot with underlying hind foot biomechanical abnormalities should not primarily be treated with a Lapidus procedure (48,49).

TECHNIQUE

An incision is made over the metatarsal–cuneiform joint approx-imately 4 to 6 cm in length. There is no incision at the level of the fi rst metatarsophalangeal joint or in the IM joint space. The tarsal–metatarsal incision is deepened in the same plane using sharp and blunt dissection. All bleeders are identifi ed and ligated as necessary. The incision is carried down exposing the metatarsal–cuneiform joint. The tarsal–metatarsal ligaments are resected using a rongeur exposing the joint. Two mini Hohman retractors are used for the soft tissue retraction and the articu-lar cartilage of the metatarsal–cuneiform joint are resected. The initial joint resection is performed on the fi rst metatarsal artic-ular surface. The fi rst metatarsal articular surface is denuded fi rst as this is the most distal and the most unstable segment. This resection is made perpendicular to the long axis of the fi rst metatarsal and parallel to the existing metatarsal base. There is no correction made within the fi rst metatarsal segment, as there is no deformity in the fi rst metatarsal of an untreated hallux

valgus/metatarsal primus varus deformity: Thus, the articular joint resection needs to be kept consistent and parallel with the natural occurring anatomy. The base of the fi rst metatarsal is concave; therefore, the amount of cartilaginous resection on the base of the fi rst metatarsal will need to be slightly greater than the amount on the convexity of the natural occurring articular surface of the cuneiform. The corrective articular resection is made at the distal aspect of the convex-shaped cuneiform. The correction is made in the transverse plane and the frontal and sagittal planes are later corrected via reduction and appropriate positioning of the tarsal–metatarsal joint.

Prior to reducing the joint into the appropriate desired posi-tion, a signifi cant amount of time should be spent with joint preparation. The metatarsal base and distal cuneiform as well as the medial aspect of the second metatarsal base are prepared. It is imperative that the surgeon is diligent to ensure that the subchondral plate is penetrated demonstrating good bleeding at both the metatarsal and cuneiform. The medial cortex of the base of the second metatarsal is débrided with a pituitary ron-geur (Fig. 31.3A). The joint preparation is extremely important in efforts to obtain a bony union and to avoid a delayed and nonunion. The recommended joint preparation techniques consist of the use of an osteotome and mallet, a 2-mm drill bit, and a bone pic (Fig. 31.3B). A substantial period of time is spent preparing this joint as this is a vital portion of the procedure to ensure good bony healing.

Next, the frontal plane is addressed. The surgeon derotates the hallux out of valgus in order to get the nail plate to be paral-lel with the ground. This derotation, allows for the entire hal-lux, sesamoid, and fi rst metatarsal complex to be rotated from a position of valgus and into a neutral position as one unit. This rotation will be clinically evident at the tarsal–metatarsal joint as well as under fl uoroscopy (Fig. 31.4). Because there is no dis-section at the fi rst metatarsophalangeal joint (medial eminence resection or sesamoidal dissection), the maintenance of the soft tissues allows the hallux, sesamoids, and metatarsal to function as one unit. The sesamoid correction can be observed under fl uoroscopy at this time.

Figure 31.2 Preoperative HAV deformity in a patient who experi-ences pain from the callous sub–second metatarsal lesion. The lesion is a direct result of the HAV deformity and the associated instability of the tarsal–metatarsal joint.

Figure 31.3 A: Intraoperative view demonstrating an incision that does not involve the fi rst metatarsal phalangeal joint. This view also demonstrates the use of a pituitary rongeur to débride the medial aspect of the base of the second metatarsal. This area is used for addi-tional attempt of stabilization between fi rst and second metatarsal. B: Intraoperative clinical view demonstrating the use of a 2-mm drill preparing the tarsal–metatarsal joint prior to fi xation.



The sagittal plane reduction technique is performed by stabi-lizing the hind foot, while the surgeon dorsifl exes the fi rst meta-tarsophalangeal joint initiating the windless mechanism. This hind foot stability allows the surgeon to apply retrograde forces to the plantar tarsal–metatarsal joint and allows for the fi rst metatarsal to plantarfl ex to a natural occurring level, parallel with the lesser metatarsals. Once the surgeon has the hallux, sesamoid, and metatarsal rotated to a neutral desirable posi-tion (frontal plane reduction), and the fi rst metatarsal sagittal

plane corrected, the surgeon can use his or her thumb against the fi rst metatarsal to manually reduce the fi rst intermetatar-sal angle in the transverse plane. The primary surgeon must ensure that the fi rst metatarsal is in the desired position, which is essentially rotated out of valgus, and parallel with the second metatarsal in both the transverse and sagittal planes. In many cases, a large Weber clamp may be used to assist, increase, or maintain the reduction (Fig. 31.5). When using the large Weber clamp, the surgeon must be sure not to change the sagittal plane

Figure 31.4 A: Preoperative AP radiograph demonstrating a large IM angle with notable valgus deformity of the great toe and a signifi cant sesamoid position with a valgus rotation. B: Intraoperative radiograph demon-strating the ability to correct the frontal plane pathology of the HAV deformity, following joint preparation of the tarsal–metatarsal. Please note the rotation of the hallux and that there is no soft tissue release performed at the metatarsophalangeal joint. C: Preoperative AP radiograph of a signifi cant HAV deformity. Please note the valgus rotation of the hallux. D: Intraoperative AP radiograph reducing the frontal plane deformity, aligning the metatarsal phalangeal joint and the sesamoids without any distal soft tissue dissection.



relationship between the fi rst and lesser metatarsals. Next a 1.6- or 2-inch smooth K-wire is used to stabilize the reduction and position. The fi rst K-wire is positioned from the central proximal one-third of the fi rst metatarsal into the cuneiform. Because of appropriate positioning of the tarsal–metatarsal joint, it is not unusual to see dorsal gapping at the tarsal– metatarsal joint. Subsequently, while maintaining position in all three planes a second K-wire is inserted into the medial fi rst metatarsal head and into the lesser metatarsals; this serves to prevent derotation in the frontal plane and maintains reduction in the transverse plane. If the surgeon feels a need to obtain more correction in the frontal plane, the K-wire can be inserted into the fi rst meta-tarsal medial and lateral cortex with the K-wire in the direction of inferior medial to superior lateral. Once the K-wire penetrates

the far cortex of the fi rst metatarsal, the K-wire can be used as a rotation device and rotate the metatarsal into more of a neutral position and insert the K-wire into the lesser metatarsal to stabi-lize the position. The position is checked both clinically as well as under fl uoroscopy to confi rm acceptable alignment.

The recommended fi xation techniques consist of interfrag-mentary compression of three solid cortical screws or an inter-fragmentary compression of solid cortical screw along with a medial based locking plate. Regardless of the construct, the fi rst screw is the most important screw; this is often referred to as the “homerun screw” (50) (Fig. 31.6). This screw should be a solid long cortical screw with preference size of a 3.5 or 4 mm. A trough is created into the middorsal side of the fi rst metatarsal approximately in the proximal one-third of the metatarsal (51). The fi rst drill is either 4 mm for a 4-mm cortical screw or 3.5 mm for a 3.5-mm cortical screw and is drilled into the fi rst metatarsal and stopped at the cuneiform. The next drill is either 2.9 mm for the 4-mm cortical screw or 2.5 mm for the 3.5-mm cortical screw and drilled into the cuneiform. The drill is aimed for the inferior, medial aspect of the cuneiform (based on the shape of the cuneiform, the largest cross section of bone is in the medial cuneiform). This screw should have a bicortical purchase; this screw provides interfragmentary compression and leverage. The interfragmentary compression will create an excellent reduc-tion at the base of the tarsal–metatarsal joint most often leaving some dorsal gapping of the tarsal–metatarsal joint.

When a three-screw construct is desired, the next screw is inserted from the medial proximal one-third of the fi rst metatar-sal under the fi rst screw with the respective drill sizes for a 3.5-mm or a 4-mm cortical screw. The initial drill is the oversized drill through the fi rst metatarsal, and the second drill is the under-sized drill into the second and or possibly the lesser metatarsals in order to obtain an excellent screw purchase. Often times a washer will be applied with this screw, which provides greater reduction of the IM angle. The third screw is placed from the most proximal dorsal position of the cuneiform aiming into the medial proximal fi rst metatarsal. This screw also should be as long as possible for obtaining leverage (52). The construct should be checked under fl uoroscopy to confi rm adequate reduction (Fig. 31.7).

Figure 31.5 Intraoperative radiograph in a case in which a large Weber clamp was used for reduction of a large IM angle.

Figure 31.6 A: An intraoperative view demonstrating the drilling of the “homerun screw” from proximal one-third to one-half the metatarsal into and exiting the most medial, inferior cortex of the medial cuneiform. B: The homerun screw is long with a bicortical purchase and is almost parallel to the ground providing a “beam effect.”



When a locking plate is used in conjunction with an inter-fragmentary compression screw the plate is applied to the medial fi rst metatarsal–cuneiform joint. Following the inser-tion of the homerun screw, the initial screws are placed proxi-mal in the medial cuneiform of the plate in combination of locking and nonlocking screws. The distal screws are placed into the metatarsal with a combination of locking and nonlock-ing screws (Figs. 31.8 and 31.9). Similar to the three-screw tech-nique, an interfragmentary compression screw can be applied

in the plate from medial to lateral into the second and/or lesser metatarsals. This interfragmentary compression allows the surgeon to reduce the IM angle well as the plate essentially becomes an excellent reduction tool acting similar to a large washer. The construct should be checked under fl uoroscopy to confi rm adequate reduction.

Attention is directed to the lateral aspect of the calcaneus where a small stab incision is made in the resting skin line that is postero-inferior to the sural nerve and the peroneal nerves. A Freer eleva-tor is inserted in the incision, freeing the periosteum medially and laterally, exposing the lateral wall of the calcaneus. A 3.5-mm drill was used to penetrate the lateral cortex. With this done, a curette is inserted into the calcaneus, allowing for harvesting of cancel-lous bone from the lateral aspect of the calcaneus (53).

The dorsal gap of the tarsal–metatarsal is packed tightly with autogenous bone graft and serves as a shear strain–relieved bone graft (52,54). The construct is checked under fl uoroscopy and the wound is closed with typical deep and skin wound sutures.

The postoperative course is dictated by the construct. It has been the experience of the authors to keep patients with the three solid cortical screw technique non-weight-bearing in a below the knee cast for 2 weeks, followed by 4 to 6 weeks of full weight-bearing in a protective fracture boot with a sound AO construct (55). The authors are encouraged with the results and believe that in the future it may be possible to allow for immedi-ate full weight-bearing in a protective fracture boot. When utiliz-ing a interfragmentary compression screw along with a medial locking plate, it has been the experience of the authors to allow immediate and full weight-bearing in a protective fracture boot.

PEARLS, TIPS, PITFALLS

During clinical assessment, it is important to assess mobility of the fi rst metatarsocuneiform joint in the sagittal, frontal, and transverse planes. While sagittal plane range of motion

Figure 31.7 Postoperative AP radiograph demonstrating the “three solid cortical screw technique” with restoration of anatomical alignment.

Figure 31.8 A: Preoperative radiograph with a HAV deformity. B,C: Postoperative radiographs demon-strating the use of an interfragmentary screw with a locking plate. Please note the restoration of anatomical alignment.



frontal plane of the fi rst metatarsophalangeal joint. Once the ligamentous structures of the tarsal–metatarsal joint is free of soft tissue attachments, rotation of the fi rst metatarsal from a valgus position in the direction of varus and into a neutral posi-tion can demonstrate the frontal plane motion associated with the pathological hallux valgus deformity.

While performing the procedure, it is vital that the entire plantar ledge of the metatarsal base and medial cuneiform are removed in entirety. If a plantar ledge remains following the osteotomy, correction will be impeded as proper place-ment and compression across the arthrodesis site will not be achieved. A transverse capsulotomy has also been advocated at the joint to decrease periosteal stripping (45).

is typically tested, transverse and frontal plane motion is often overlooked. The use of the fi rst ray splay test is a rele-vant method to determine if transverse plane hypermobility needs to be addressed. The foot is positioned with the subta-lar joint and midtarsal joint in neutral, and direct transverse plane pressure is applied with the thumb and index fi nger to the fi rst and second metatarsal heads. If hypermobility is dem-onstrated, with the addition of fi xation between the fi rst and second metatarsals, a fi rst metatarsal base–second metatarsal base arthrodesis may be advocated (56). Unfortunately, to the best of the author’s knowledge, there is no known preoperative frontal plane motion stress test. Intraoperatively, the authors have been able to demonstrate the dynamic changes in the

Figure 31.9 A,B: Preoperative radiograph and clinical photo of a patient with HAV deformity. C,D: Postop-erative radiograph and clinical photo of the patient with the use of an interfragmental compression screw and a medial based locking plate. The correction can be seen in all three planes.



taken to not plantarfl ex the fi rst ray as sesamoiditis could result. Overcorrection and undercorrection are also encountered.

Although the authors do not advocate it for this procedure, if a traditional lateral fi rst metatarsal interspace release is performed, hallux varus is a possible complication. This is a complication that can accompany any procedure that uses the lateral release.

Hardware failure can result from improper placement and/or unsuitable techniques. In cases of hardware failure, subse-quent surgery to remove the hardware is performed.

Neuritis, while uncommon, can be encountered with the close proximity of the medial dorsal cutaneous nerve to the surgical site. Depending upon dissection techniques and incision planning, the saphenous nerve may be involved as well as the deep peroneal nerve of the fi rst interspace (17,27,46). Cases of complex regional pain syndrome status past surgery have been reported (63).

REFERENCES

1. Albrecht GH. The pathology and treatment of hallux valgus (Russian). Russk Vrach 1911;10:14–19.

2. Truslow W. Metatarsus primus varus or hallux valgus. J Bone Joint Surg 1925;7:98–108. 3. Lapidus PW. Operative correction of the metatarsus varus primus in hallux valgus. J Surg

Gynecol Obstet 1930;58:183–191. 4. Chang T, Ruch J. Lapidus arthrodesis A different perspective. J Am Podiatr Med Assoc

1994;6:281–288. 5. Hofbauer M, Grossman J. The Lapidus procedure. Clin Podiatr Med Surg 1996;3:485–496. 6. Sangeorzan B, Hansen S. Modifi ed Lapidus procedure for hallux valgus. Foot Ankle

1989;6:262–266. 7. Butson ARC. A modifi cation of the Lapidus operation for hallux valgus. J Bone Joint Surg

1980;62B:350–352. 8. Bacardi BE, Boysen TJ. Considerations for the Lapidus operation. J Foot Surg 1986;25:138. 9. Hernandez A, Hernandez PA. Lapidus: when and why?. Clin Podiatr Med Surg 1989;6:197.10. Mauldin DM, Sanders M, Whitmer WW. Correction of hallux valgus with metatarsocunei-

form stabilization. Foot Ankle 1990;11:5711. Myerson M. Metatarsocuneiform arthrodesis for treatment of hallux valgus and metatarsus

primus varus. Orthopedics 1990;13:1050.12. Neylon T, Johnson B, Laroche R. Use of the Lapidus bunionectomy in fi rst ray insuffi -

ciency. Clin Podiatr Med Surg 2001;2:365–375.13. Root ML, Orien WP, Weed JH. Muscle function of the foot during locomotion. In: Root

ML, O’Rien WOP, Weed JH, eds. Clinical biomechanics, vol 2. Los Angeles, CA: Clinical Biomechanics Corporation, 1977.

14. Root ML, Orien WP, Weed JH, et al. Technique for the examination of the fi rst ray. In: Root SA, ed. Biomechanical examination of the foot, vol 1. Los Angeles, CA: Clinical Biomechanics, 1971:80–87.

15. Bednarz PA, Manoli A. Modifi ed Lapidus procedure for the treatment of hypermobile hallux valgus. Foot Ankle Int 2000;10:816–821.

16. Roukis TS, Landsman AS. Hypermobility of the fi rst ray: a critical review of the literature. J Foot Ankle Surg 2003;6:377–390.

17. Myerson M, Allon S, McGarvey W. Metatarsocuneiform arthrodesis for management of hallux valgus and metatarsus primus varus. Foot Ankle 1992;13:107–115.

18. Klaue K, Hansen ST, Masquelet AC. Clinical, quantitative assessment of fi rst tarsometatar-sal mobility in the sagittal plane and its relation to hallux valgus deformity. Foot Ankle Int 1994;15:9–13.

19. Lapidus PW. The author’s bunion operation from 1931 to 1959. Clin Orthop 1960;16:119–135.20. Romash MM, Fugate D, Yanklowit B. Passive motion of the fi rst metatarsal cuneiform joint:

Preoperative assessment. Foot Ankle 1990;10:293–299.21. Catanzariti AR, Mendecino RW, Lee MS, et al. The modifi ed Lapidus arthrodesis: a retro-

spective analysis. J Foot Ankle Surg 1999;38:322–332.22. Grace D, Delmonte R, Catanzariti AR, et al. Modifi ed Lapidus arthrodesis for adolescent

hallux abducto valgus. J Foot Ankle Surg 1999;38:8–13.23. Rutherford RL. The misuse of the Lapidus procedure [letter]. J Foot Ankle Surg

1997;36:74–76.24. Goldner JL, Gaines R. Adult and juvenile hallux valgus: analysis and treatment. Orthop Clin

1976;7:863–887.25. Piggot H. The natural history of hallux valgus in adolescent and early adult life. J Bone Joint

Surg Br 1960;42-B:749–760.26. Vyas S, Conduah A, Vyas N, et al. The role of the fi rst metatarsocuneiform joint in juvenile

hallux valgus. J Pediatr Orthop B 2010;5:399–402.27. Clarke HR, Veith RG, Hansen ST. Adolescent bunions treated by the modifi ed Lapidus

procedure. Bull Hosp Jt Dis Orthop Inst 1987;47:109–122.28. Scranton PE, Zuckerman JD. Bunion surgery in adolescents: results of surgical treatment.

J Pediatr Orthop 1984;4:39–43.29. Saffo G, Desnoyers R, Wooster M, et al. First metatarsocuneiform joint arthrodesis: a fi ve

year retrospective analysis. J Foot Surg 1989;5:459–465.30. McCrea J, Lichty T. The fi rst metatarsocuneiform articulation and its relationship to meta-

tarsus primus adductus. J Am Podiatr Assoc 1979;12:700–706.

Bone grafting has been heavily used in this procedure both for maintenance of length of the fi rst ray as well as to aid in arthrodesis to prevent delayed and nonunions. Historically, cancellous bone harvested percutaneously from the calcaneus, tricortical grafts from the iliac crest as well as the medial emi-nence from the fi rst metatarsal head have been successfully used as grafting material (6,7,57,58). If grafting is not performed, the surgeon should consider plantarfl exing the metatarsal to accommodate for the shortening; however, caution is advised as it has been reported that a 3-mm wedge resection results in approximately 1 cm of plantarfl exion (4,59).

Concomitant deformities and biomechanical abnormalities need to be addressed when performing this procedure, such as equinus (48). If other deformities are not corrected biomechan-ical compensations may occur that hinder the primary surgical correction (60). Early protective weight-bearing status starting at 2 weeks postoperatively has been successful when 3 points of fi xation or locking plates are used (55,61,62). The authors advocate the use of a homerun screw, a fully threaded cortical screw inserted with AO standard lag technique oriented from dorsal distal to proximal plantar from the fi rst metatarsal base to the medial cuneiform (52). The second screw, a fully threaded 4-mm cortical screw, is then inserted with AO standard lag tech-nique perpendicular to the homerun screw, which is driven into the base of the second metatarsal to increase reduction of the fi rst to second IM angle. The third screw, another 4-mm fully threaded cortical screw, is inserted with standard AO lag technique oriented across the fi rst metatarsal–cuneiform joint from proximal dorsal lateral to distal plantar lateral and should cross with the homerun screw. The authors allow for early post-operative weight-bearing at 2 weeks when using this technique. This early weight-bearing may decrease incidence of deep venous thrombosis, decrease morbidity to the patient, and improve function following the surgical procedure.

In order to achieve a favorable outcome, the surgeon must spend most of his or her time obtaining good anatomical align-ment, joint preparation as well as creating a rigid construct with good fi xation.

COMPLICATIONS

Signifi cant shortening of the fi rst metatarsal can be a complica-tion of the Lapidus procedure. Shortening of the fi rst metatar-sal can lead to transfer lesions plantar to the second metatarsal head as well as decreased hallux purchase. Current grafting tech-niques and proper positioning of the metatarsal during arthro-desis have made this a less common encountered complication.

Delayed unions and nonunions should be noted as compli-cations, with delayed unions occurring more frequently in lit-erature (63). Nonunions have had a reported incidence of up to 12% following fi rst metatarsal–cuneiform arthrodesis (29). Grafting of the prepared joint surface and advanced internal fi xation techniques of 3-point fi xation and locking plates have signifi cantly decreased the rate of delayed unions and nonun-ions. Nonunions have been reduced to reports of 0% (7).

Malunions associated with the procedure can be avoided with intraoperative radiographs to establish correct positioning in all three planes of motion. A malunion in an elevatus posi-tion of the fi rst ray may give rise to a dorsal bunion, decreased range of motion, and decreased purchase of the fi rst ray, which could lead to transfer metatarsalgia (17). Likewise, care must be



47. Coughlin MJ, Mann RA. Hallux valgus. In: Coughlin MJ, Mann RA, Saltzman CL, eds. Surgery of the foot and ankle, 8th ed. Philadelphia, PA: Mosby Elsevier, 2007:183–362.

48. Barvarian B, Briskin GB, Burns P. Lapidus bunionectomy: arthrodesis of the fi rst metatar-socuneiform joint. Clin Podiatr Med Surg 2004;21:97–111.

49. Fuhrmann RA. Arthrodesis of the fi rst tarsometatarsal joint for correction of the advanced splayfoot accompanied by a hallux valgus. Oper Orthop Traumat 2005;2:195–210.

50. Hansen ST, MD, oral communication.51. Manoli A, Hansen ST. Screw hole preparation in foot surgery. Foot Ankle Int 1990;11:

105–106.52. Hansen ST, ed. Functional reconstruction of the foot and ankle, 1st ed. Philadelphia, PA:

Lippincott Williams & Wilkins, 2000.53. DiDomenico LA, Haro AA. Percutaneous harvest of calcaneal bone graft. J Foot Ankle Surg

2006;2:131–133.54. Perren SM. Physical and biological aspects of fracture healing with special reference to

internal fi xation. Clin Orthop Relat Res 1979;(138):175–196.55. Blitz NM, Lee T, Williams K, et. al. Early weight bearing after modifi ed Lapidus arthrodesis:

a multicenter review of 80 cases. J Foot Ankle Surg 2010;49:357–362.56. Weber AK, Hatch DJ, Jensen JL. Use of the fi rst ray splay test to assess transverse plane

instability before fi rst metatarsocuneiform fusion. J Foot Ankle Surg 2004;4:278–282.57. Giannestras N. In: Giannestras N, ed. Foot disorders: medical and surgical management.

Philadelphia, PA: Lea & Febiger, 1973.58. Ruch JA, Chang TJ. Relative strengths and effi cacy of fi xation techniques in osteotomies

and arthrodesis of the fi rst metatarsal. In: Ruch JA, Vickers NS, eds. Reconstructive surgery of the foot and leg-update 1992. Tucker, GA: Podiatry Institute, Inc, 1992:233--235.

59. Thompson IM, Bohay DR, Anderson JG. Fusion rate of fi rst tarsometatarsal arthrodesis in the modifi ed Lapidus procedure and fl atfoot reconstruction. Foot Ankle Int 2005;698–703.

60. DiDomenico LA, Adams HB, Garchar D. Gastrocnemius recession for the treatment of gastrocnemius recession. J Am Podiatr Med Assoc 2005;95(4):410–413.

61. Basile P, Cook EA, Cook JJ. Immediate weight bearing following modifi ed Lapidus arthrod-esis. J Foot Ankle Surg 2010;49:459–464.

62. Sorensen MD, Hyer CF, Berler GC. Results of Lapidus and locked plating with early weight bearing. Foot Ankle Spec 2009;2:227–233.

63. Rink-Brune O. Lapidus arthrodesis for management of hallux valgus—a retrospective review of 106 cases. J Foot Ankle Surg 2004;43(5):290–295.

31. Haas Z. Maintenance of correction of fi rst metatarsal closing base wedge osteotomies ver-sus modifi ed Lapidus arthrodesis for moderate to severe hallux valgus deformity. J Foot Ankle Surg 2007;5:358–365.

32. Cooper A, Clifford P, Parikh V, et al. Instability of the fi rst metatarsal-cuneiform joint: diagnosis and discussion of an independent pain generator in the foot. Foot Ankle Int 2009;10:928–932.

33. Morton DJ. Evolution of the longitudinal arch of the human foot. J Bone Joint Surg 1924;6:56–90.

34. Morton DJ. Hypermobility of the fi rst metatarsal bone. Bone Joint Surg 1928;10:187–196.35. Morton DJ. Structural factors in static disorders of the foot. Am Surg 1930;9:315–328.36. Morton DJ. The human foot: Its evolution, physiology and functional disorders. New York, NY:

Columbia University Press, 1935.37. Morton DJ. Metatarsus atavicus, the identifi cation of a distinctive type of foot disorder.

J Bone Joint Surg 1927;9:531–544.38. Catanzariti AR. First metatarsocuneiform joint arthrodesis. In: Marcinko DE, ed. Comprehensive

textbook of hallux abducto valgus reconstruction. St. Louis, MO: Mosby-Yearbook, 199239. Bierman RA, Christensen JC, Johnson CH. Biomechanics of the fi rst ray. Part III.

Consequences of Lapidus arthrodesis on peroneus longus function: a three-dimensional kinematic analysis in a cadaver model. J Foot Ankle Surg 2001;3:125–131.

40. Avino A, Patel S, Hamilton G, et al. The effect of the Lapidus arthrodesis on the medial longitudinal arch: A radiographic review. J Foot Ankle Surg 2008;6:510–514.

41. Logel KJ, Parks BG, Schon L. Calcaneocuboid distraction arthrodesis and fi rst metatarso-cuneiform arthrodesis for correction of acquired fl atfoot deformity in a cadaver model. Foot Ankle Int 2007;4:435–440.

42. Frankel J, Larsen D. The misuse of the Lapidus procedure: re-evaluation of the preopera-tive criteria. J Foot Ankle Surg 1996;4:355–361.

43. Catanzariti AR. Modifi ed medial column arthrodesis. J Foot Ankle Surg 1993;2:180–188.44. Coetzee JC, Resig SG, Kuskowski M, et al. The Lapidus procedure as salvage after failed sur-

gical treatment of hallux valgus. Surgical technique. J Bone Joint Surg Am 2004;86-A:30–36.45. Mote GA, Yarmel D, Treaster A. First metatarsal-cuneiform arthrodesis for the treatment of

fi rst ray pathology: a technical guide. J Foot Ankle Surg 2009;5:593–601.46. Catanzariti AR, Blitch EL. Metatarsal cuneiform procedures. In: Banks AS, Downey MS,

Martin DE, et al., eds. McGlamry’s comprehensive textbook of foot and ankle surgery, 3rd ed. Philadelphia, PA: Lippincott Williams & Wilkins, 2001:544–556.


Mari Wargo-Dorsey Lapidus Bunionectomy: First Metatarsal– Cuneiform Arthrodesis · 2013-04-04 ·...

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